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Prescriptions Not Filled

Written by Jon Barron at The Baseline of Health Foundation
02/03/2011

It's as predictable as snow in Montana: when you go to the doctor, you're going to leave with a prescription. Most doctors feel that they aren't doing their job if they don't routinely offer their patients pills or some form of medical "solution." They claim that patients expect and need drugs in order to heal, and the pharmaceutical companies wholeheartedly endorse that position. But a recent study shows that in fact, many patients who leave the office with a prescription never bother to get it filled.

The study, just published in the Journal of General Internal Medicine, found that of 75,000 prescriptions written over the course of a year in Massachusetts, 22% of them were never submitted to a pharmacy for filling. The rate of "noncompliance" was even higher for certain types of prescriptions. For instance, almost a third of first-time prescriptions (28%) were never filled. The same goes for prescriptions for chronic conditions like diabetes and high blood pressure, which weren't filled 31% of the time. On the other hand, pain medication prescriptions garnered a far higher rate of noncompliance, with a whopping 65 percent of all prescriptions in this category never filled.

The researchers don't really know why so many patients never obtain the medications prescribed for them, but they do have a prescription to remedy the situation: better doctor-patient communication. "If [patients] do not fully understand the reason that they are being prescribed the medication, they may be less likely to take it," said Dr. Michael A. Fischer, of Brigham and Women's Hospital in Boston. "If you are not sure why you are being prescribed a medication, ask your doctor directly. One of our jobs as physicians is to educate and advise our patients, and being sure that they understand their medication regimen is a big part of that job."

Dr. Fischer suggests that many illnesses don't manifest disturbing symptoms, and so patients feel no critical need to rush to the drugstore for a cure. He feels that if doctors do not properly educate their patients, those patients will think bypassing the prescription is no big deal. The hole in Dr. Fischer's theory is the 65 percent of patients who fail to follow through on their pain medication prescription. Certainly patients in pain need no education to understand that the medication might diminish their discomfort. Still, they choose to forego their prescriptions.

Experts also point to the expense of prescription medication as a factor in noncompliance, although all the patients in the study had health insurance to cut the cost of drugs. And in fact, an earlier study by the Kaiser Foundation discovered that 29 percent of the people in the study never filled their prescriptions because of the expense, while 18 percent cut their medications in half for the same reason. This indicates that cost may well be a factor, even among those whose insurance covers part of the cost.

Other research has turned up similar results. In fact, the rate of non-filled prescriptions seems to be escalating. A study a few years ago found that between 2007 and 2008, the number of prescriptions ordered by physicians and then left at the drugstore rose by 22 percent. When compared to the year before that (2006), the increase in abandoned prescriptions rose by 34 percent. A separate study found that one in three diabetics failed to fill their prescriptions in 2009, and yet another concluded that a quarter of heart-attack survivors don't fill the prescriptions intended to prevent future attacks.

Naturally, the medical community finds patient resistance to filling prescriptions a worrisome trend. (I can only imagine what the pharmaceutical companies think.) And while it is true that cost may play a role in this scenario (a subject for a future discussion) and that poor doctor-patient communication may also factor in, it is equally possible that something else is going on. Perhaps the public has caught wind of the fact that prescription drugs are now the fourth leading cause of death in the US, just behind cancer, heart disease, and stroke -- not to mention hospital error, which we explored in a blog just a few days ago. Or perhaps they've heard that 2.2 million people in the US experience drug-related disabilities or serious drug reactions each year. Maybe they even know somebody who has been the victim of a drug reaction or prescribing error. Maybe they're smart enough to be scared by the page-long list of possible side effects that goes into the bag along with the bottle of pills. In fact, perhaps many people these days actually get on the internet and look up the drug they've been prescribed before ordering it. Maybe they even research the possibility of alternatives.

The reality is that although there is a role for pharmaceuticals in our healthcare, it doesn't take a Mensa member to recognize that prescription drugs cause lots of problems for lots of people, and that the cost (on all levels) sometimes isn't worth it for the benefit gained. Unfortunately, although that's true, it's also true that sometimes prescription drugs really can save lives, and a scared public may not be savvy about differentiating between useless, dangerous drugs and necessary ones. In one of the studies cited above, the 25 percent of heart-attack patients who opted not to fill their prescriptions after their cardiac arrest had an 80 percent higher death rate in the year following their attack compared to those patients who took the recommended medication. There's a case where education, in the form of data that patients could believe in, might have made a difference. Or then again, maybe they never acted on any of the alternatives they may have learned about, since those alternatives take discipline and require effort. And doing nothing is not usually a smart alternative.

And that's the point. Educating patients doesn't mean brainwashing them into accepting they must take their pills -- or else. To truly educate patients means that doctors need to give patients some credit for having brains--to let them see the statistics and weigh for themselves risks versus benefits. It also means that doctors need to present patients with alternatives when those exist and to support patients in following safe alternate regimens. Whether people take their medications or not isn't the point. The point is that health professionals need to assess what will help people to heal and to get stronger without creating even worse health problems as a result of the treatment. The healing community needs to do what it can to make sure that's where the emphasis resides, because that is what will create trust between doctors and patients and promote true communication.

Re: Prescriptions Not Filled

Superb analysis-very balanced and thoughtful. I have always respected Jon Barron; reading this increases my respect. I do appreciate his acknowledgement that we do need some pharmaceuticals in medicine but we as health professionals need to use treatments that heal not harm.
I agree with his surmise that increasing numbers of people are afraid of prescription drug side effects-I mention to people I can't take drugs and I hear "I can't tolerate ___ or that made me sick or my mother had this funny reaction" much more often than 10 years ago.

Re: Prescriptions Not Filled

"Dr. Fischer suggests that many illnesses don't manifest disturbing symptoms, and so patients feel no critical need to rush to the drugstore for a cure."
A cure? At a drugstore? Is it possible that he believes that or does he just expect patients to believe that?

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